"The stay here is, of course, not appropriate for an old person": the perspective of healthcare providers on older patients in the emergency department

BACKGROUND

In aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work.

METHODS

The study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective.

RESULTS

The interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of 'the geriatric patient'. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service.

CONCLUSION

Healthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients.

Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare

BACKGROUND

Appreciative Inquiry is a motivational, organisational change intervention, which can be used to improve the quality and safety of healthcare. It encourages organisations to focus on the positive and investigate the best of 'what is' before thinking of 'what might be', deciding 'what should be' and experiencing 'what can be'. Its effects in healthcare are poorly understood. This review seeks to evaluate whether Appreciative Inquiry can improve healthcare.

METHODS

Major electronic databases and grey literature were searched. Two authors identified reports of Appreciative Inquiry in clinical settings by screening study titles, abstracts and full texts. Data extraction, in duplicate, grouped outcomes into an adapted Kirkpatrick model: participant reaction, attitudes, knowledge/skills, behaviour change, organisational change and patient outcomes.

RESULTS

We included 33 studies. One randomised controlled trial, 9 controlled observational studies, 4 qualitative studies and 19 non-controlled observational reports. Study quality was generally poor, with most having significant risk of bias. Studies report that Appreciative Inquiry impacts outcomes at all Kirkpatrick levels. Participant reaction was positive in the 16 studies reporting it. Attitudes changed in the seventeen studies that reported them. Knowledge/skills changed in the 14 studies that reported it, although in one it was not universal. Behaviour change occurred in 12 of the 13 studies reporting it. Organisational change occurred in all 23 studies that reported it. Patient outcomes were reported in eight studies, six of which reported positive changes and two of which showed no change.

CONCLUSION

There is minimal empirical evidence to support the effectiveness of Appreciative Inquiry in improving healthcare. However, the qualitative and observational evidence suggests that Appreciative Inquiry may have a positive impact on clinical care, leading to improved patient and organisational outcomes. It is, therefore, worthy of consideration when trying to deliver improvements in care. However, high-quality studies are needed to prove its effects.

PROSPERO REGISTRATION NUMBER

CRD42015014485.

Appreciative inquiry in a Norwegian nursing home: a unifying and maturing process to forward new knowledge and new practice

PURPOSE

Appreciative inquiry (AI) studies have proven to be useful in developing nursing knowledge and changing nursing practice. However, few AI studies have examined the meaning of participation over time among collaborating healthcare providers. Our aim was to explore and illuminate healthcare providers' participation over time in a Norwegian nursing home to develop new knowledge and practice, focusing on sensory gardens.

METHOD

Twenty healthcare providers participated in the 3 year AI study. Data were collected in fieldwork, interviews, and interventions. Saldañas' longitudinal analysis was applied.

RESULTS

The collaboration between the researcher and participants created insight of a relational room, which was named "the room of closeness". Participants' search for new arenas to apply the meaning of the room of closeness was found when focusing on the sensory garden. Their desire for joint development created a bottom-up perspective, the hallmark of successful AI.

CONCLUSION

Knowledge of participants' experiences may contribute to developing AI as a useful and transferable method, especially regarding co-creating participation, and may have implications for research and society. AI's strength-based approach may, however, lead to the neglect of data that are associated with problems, and complicate the assessment of success. Further research is therefore needed to develop AI.

Communication skills in nursing: A phenomenologically-based communication training approach

The aim of this article is to present a communication skills training curriculum for nursing students, based upon phenomenology. Research shows that nurses have difficulty prioritizing dialogue with patients, due to lack of time, organizational and cultural factors. Like other health care professionals, nurses may also have difficulties communicating with patients due to personal fears and shortcomings. The communication training curriculum based upon phenomenology aims at systematically training students to stay focused upon patients' and relatives' narratives, allowing them to reflect upon and better understand their current situation. This approach to communication is applicable in any clinical situation where it important to provide space for the patients' experiences. The philosophical principles guiding the training are presented here as well as the practical steps in the program. Finally, the approach is compared to other common communication methods used in nursing (motivational interviewing, caring conversations, empathy training). The authors hope that the article will highlight the nurses' role as dialogue partner as well as emphasize the importance of communication skills training in nursing education. This approach can be refined, tested and modified in future research and may serve as an inspirational model for creating a generic communicative competence for nurses. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Caring for an older person with dementia in the Emergency Department (ED): An Appreciative Inquiry exploring family member and ED nurse experiences

AIMS AND OBJECTIVES

To generate insights about what matters and is valued by family members of older people with dementia in the emergency department. To explore the experiences of emergency nurses looking after older people with dementia in an episode of care.

BACKGROUND

In the emergency department, older people with dementia are at risk of suboptimal care. Little is known of the experiences of family members of being with an older person with dementia in the emergency department or the experiences of emergency nurses looking after older people with dementia in this environment.

DESIGN AND METHODS

Phase 1 Data Analysis of the Discovery Phase of an Appreciative Inquiry study. Study participants were family members of older people with dementia and emergency nurses. Data collection methods included interviews with family members of older people with dementia and 30 hr of participant observation working alongside emergency nurses. This study was guided by the Standards for Reporting Qualitative Research.

RESULTS

Two themes emerged from the analysis: What matters to family members with four subthemes and challenges for family members and nurses in the emergency department with two subthemes.

CONCLUSION

This study demonstrates that some emergency nurses are connecting with family members even in the briefest of clinical encounters. It is feasible for more emergency nurses to do the same more of the time.

RELEVANCE TO CLINICAL PRACTICE

The older person with dementia must be given a triage category of no less than 3 (to be seen by the doctor within the hour) on arrival in the department. Further education is needed to assist emergency nurses to establish rapport and incorporate family member insights as part of care planning and assessment of the needs of the older person with dementia.

Enabling At-Homeness for Older People With Life-Limiting Conditions: A Participant Observation Study From Nursing Homes

At-homeness, as an aspect of well-being, can be experienced despite living with life-limiting conditions and needs for a palliative approach to care. In nursing homes, older residents with life-limiting conditions face losses and changes which could influence their experience of at-homeness. The aim of this study was to explore how nursing staff enable at-homeness for residents with life-limiting conditions. Interpretive description was employed as the design using data from participant observations and formal and informal interviews related to nursing care situations. The strategies found to be used to enable at-homeness comprising nursing staff presenting themselves as reliable, respecting the resident's integrity, being responsive to the resident's needs, collaborating with the resident in decision-making, and through nurturing comforting relationships. The result on how to enable at-homeness could be used as strategies for a person-centered palliative approach in the care for residents in nursing homes.

Leading with compassion in health care organisations

Purpose The purpose of this paper is to report an evaluation of a leading-with-compassion recognition scheme and to present a new framework for compassion derived from the data. Design/methodology/approach Qualitative semi-structured interviews, a focus group and thematic data analysis. Content analysis of 1,500 nominations of compassionate acts. Findings The scheme highlighted that compassion towards staff and patients was important. Links to the wider well-being strategies of some of the ten organisations involved were unclear. Awareness of the scheme varied and it was introduced in different ways. Tensions included the extent to which compassion should be expected as part of normal practice and whether recognition was required, association of the scheme with the term leadership, and the risk of portraying compassion as something separate, rather than an integral part of the culture. A novel model of compassion was developed from the analysis of 1,500 nominations. Research limitations/implications The number of respondents in the evaluation phase was relatively low. The model of compassion contributes to the developing knowledge base in this area. Practical implications The model of compassion can be used to demonstrate what compassion "looks like", and what is expected of staff to work compassionately. Originality/value A unique model of compassion derived directly from descriptions of compassionate acts which identifies the impact of compassion on staff.